MS-2156

Medical Review of Emergency Services 10-01

For Establishing SOBRA Eligibility

(except Labor and Delivery)

I. REQUEST FOR INFORMATION (to be completed by local dcf office)
Individual’s Name:
(First) / (Middle) / (Last)
Birthdate: / Case Number: / Medicaid ID#:

The above-named person has applied for medical assistance from the Kansas Department for Children and Families, and information is needed to determine if the medical services provided were for an emergency medical condition after the sudden onset of a medical condition manifested by symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: (a) placing the patient’s health in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part.

DCF Specialist: / Phone #:
Office Location:
Address: / City, State, Zip:
II. VERIFICATION OF EMERGENCY SERVICES (to be completed by provider)

In order to verify the emergent nature of the services, the following information must be provided, this form attached to those records and the entire document mailed to: Kansas Medical Assistance Program, Office of the Fiscal Agent, CC:765L, SOBRA Staff, P.O. Box 3571, Topeka, KS 66601-3571. This form is not required for routine labor and delivery services.

To ensure timely processing this form and all documents must be submitted to the fiscal agent within 30 days from receipt of this form.

Payment for services may not be made without the following documentation:

A. For Hospital Services (Inpatient, Outpatient, ER)B. For All Other Outpatient Service

1. History (i.e., Physician, FQHC, RHC, etc.)

2. Physical

3. Admission & Discharge Summary1. Exam Notes

4. Emergency Room Records with Doctor’s2. History

Exam and Notes

Services meeting the above criteria were rendered on the following date(s): / Through
Provider Name: / Provider Phone Number:
Provider’s Signature (or Designee) / Address / Date Form Completed
III. MEDICAL REVIEW (to be completed by SOBRA Manager or Fiscal Agent Staff)
Decision:
Date:
Authorized Reviewer’s Signature

INSTRUCTIONS FOR MS-2156

Part I must be completed by local DCF Office staff and forwarded to the appropriate provider for form completion and records request.

Part II must be completed by the appropriate provider, signed and attached to the records described within the section, then mailed to:

Kansas Medical Assistance Program

Office of the Fiscal Agent, CC:765L

Attn: SOBRA staff

P. O. Box 3571

Topeka, Kansas 66601-3571

Part III must be completed by SOBRA Manager or designated Fiscal Agent staff and returned to local DCF Office for eligibility finalization.